Westchester Manor at Providence Place

In the surveyor’s words

From the most serious findings on record at Westchester Manor at Providence Place, in the surveyor’s own words.

• Actual harm, isolatedF600May 23, 2024

  Based on observations, record review, staff and nurse practitioner interviews the facility failed to protect a resident's right to be free from abuse (Resident #13) when another resident (Resident #44) pulled out a section of hair from Resident #13. This deficient practice occurred for 1 of 3 residents reviewed for physical abuse. The reasonable person concept was applied for Resident #13 due to a reasonable person would feel pain and emotional distress having his or her hair pulled out of their head by another person. […]

• No harm, potential for more than minimal, patternF809Jul 24, 2025

  Based on staff and Registered Dietitian (RD) interviews and record review, the facility failed to have no greater than a 14 hour lapse between the provision of a substantial evening meal and breakfast the following day for residents served their meals on 6 of 6 halls (400 Hall, 500 Hall, 600 Hall, 300 Hall, 200 Hall and 100 Hall).The findings included:A schedule of the Meal Service Times (Starting January 1, 2025) was provided upon entry to the facility. A review of this schedule indicated the delivery times for each hallway allowed 14 hours and 30 minutes to elapse between the last meal of the day and first meal of the following day as follows:--The 400 Hall meals were scheduled to be delivered at 5:15 PM for dinner and at 7:45 AM for breakfast (indicative of a 14-hour and 30-minute time… […]

• No harm, potential for more than minimal, patternF812Jul 24, 2025

  Based on observations and interviews with the facility staff, the facility failed to: 1) Label, date, and seal opened food items stored in the Dietary Department's walk-in freezer; 2) Dispose of expired food items stored in the reach-in refrigerator; and 3) Cover facial hair for 2 of 2 Dietary staff observed with facial hair and working with food preparation in the kitchen (Dining Services Director and [NAME] #1. These practices had the potential to affect food being served to residents.The findings included:1) Accompanied by the Dining Services Director, an initial tour was conducted of the Dietary Department on 7/21/25 at 9:29 AM. […]

• No harm, potential for more than minimal, patternF692Oct 20, 2021

  Based on observations, record review, and staff interviews, the facility failed to transcribe an ordered dietary supplement for 1 of 5 residents (Resident #74) reviewed for nutrition. The findings included: Resident #74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #74 weight on 8/4/2021 was 190.2 pounds. Resident #74 was discharged to the hospital on 8/26/2021 and readmitted to the facility on [DATE] with a weight of 146.4 pounds. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #74 was cognitively impaired for making decisions of daily living and required one staff member assistance with eating. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF684Aug 13, 2026

  Based on record review and interviews with staff and the Medical Director, facility staff failed to report a witnessed accident that resulted in an approximately 3.5 centimeters laceration over Resident #129's right eye which delayed her transfer to the hospital for evaluation and treatment. Nurse Aide #1 did not report the accident or bleeding to the nurse. The laceration was discovered by the nurse later in the night and the resident was sent to the hospital and the laceration was closed with three sutures. This deficient practice was identified for 1 of 3 residents sampled for supervision to prevent accidents (Resident #129). The findings included: Resident #129 was admitted to the facility on [DATE] with diagnoses of muscle weakness and anemia. […]